Relational measures in psychotherapy research on process and outcome: a commentary on the studies

Using Benjamin's (2000) Structural Analysis of Social Behavior, we evaluated change in "self-directed" affiliation and autonomy and prediction of treatment response and relapse/recurrence among adult outpatients with recurrent major depressive disorder consenting to acute phase cognitive therapy (A-CT; Beck, Rush, Shaw, & Emery, 1979; N=156); A-CT responders randomized (N=84) to 8 months of continuation phase cognitive therapy (C-CT; Jarrett, 1989; Jarrett et al., 1998; Jarrett & Kraft, 1997) or assessment-only control; and C-CT and control patients entering a 16-month, assessment-only follow-up (N=74). Self-directed affiliation and autonomy increased after A-CT, and C-CT further increased affiliation and autonomy. Affiliation and autonomy did not predict A-CT response, but lower affiliation and higher autonomy pre-A-CT predicted relapse/recurrence post-A-CT. We discuss potential clinical implications of these results and present case examples to illustrate patterns of change.     

A daily process approach to coping. Linking theory, research, and practice

For decades, coping researchers have used between-person designs to address inherently within-person questions derived from theory and clinical practice. The authors describe recent developments in the use of within-person, process-oriented methods that examine individuals intensively over time. Ongoing studies of stress and alcohol consumption, the effects of depression on adaptational processes, and the temporal dynamics of coping with chronic pain demonstrate that by tracking rapidly fluctuating processes such as mood and coping close to their real-time occurrence, daily process designs offer unique insights into conceptually and clinically challenging questions. Such designs also provide new opportunities to examine the purported mechanisms of therapeutic interventions. Despite its demands on participants and investigators, daily process research offers fresh opportunities to link psychological theory, research, and practice.     

Emotional inertia: A key to understanding psychotherapy process and outcome

The processes underlying psychotherapeutic change have increasingly been emphasized in both research and clinical practice. Nonlinear dynamical systems theory (NDS) offers a transdisciplinary scientific approach to the study of these processes. This paper introduces the NDS concept of “emotional inertia”, the property of human emotion by which it retains its course so long as it is not acted upon by an external force, as a key to understanding moment-by-moment and also longer-term change processes within psychotherapy. A testable mathematical model of emotional inertia is presented that represents specific impacts of psychotherapeutic processes on emotional dynamics over time. Emotional trajectories in phase space, treatment energy, and the interaction between them are the essential elements of the model, and a detailed explanation is provided. Procedures for testing this model are described, such as by tracking the movement of emotion in phase space within and across therapy sessions, along with clinical implications of the model, which can potentially help to make more clear the complementary roles of therapeutic force, timing, and leverage.     

Stress,healthiness and health behaviours: An exploration of the role of life events,daily hassles,cognitive appraisal and the coping process

In a study of 220 participants, the relationship between life events, daily hassles, cognitive appraisal and coping, stress and general healthiness was investigated utilizing a self report methodology. The different aspects of healthiness and health behaviour/lifestyle appear to be related to different appraisal and coping styles. The role of daily hassles and life events in the process also vary across different aspects of health, illness and health behaviours. In fact the number of life events experienced appear to contribute more to hardiness than to vulnerability. It is proposed that to understand the process an integrative model is required which allows for flexibility in analysis.     

The role of neuroticism in daily stress and coping

The authors examined the influence of neuroticism (N) on the occurrence of different types of daily events, primary and secondary appraisals of those events, use of specific coping strategies, and end-of-day negative mood. College students completed questionnaires at the end of every day for 14 consecutive days. When reporting their most stressful event of each day, high-N individuals, compared with low-N individuals, reported more interpersonal stressors and had more negative primary and secondary appraisals and reacted with more distress in response to increasingly negative primary and secondary appraisals. Compared with low-N individuals, high-N individuals used less-adaptive coping strategies (e.g., hostile reaction) and reacted with more distress in response to some types of coping strategies. The appraisal findings, in particular, help to explain the chronic negative affectivity associated with neuroticism.     

Depression history and coping with chronic pain: a daily process analysis.

This study examined how a previous episode of depression is related to daily pain and reactions to pain among individuals with fibromyalgia, a chronic pain syndrome. Seventy-one women with fibromyalgia (including 30 who were previously depressed) rated their pain and mood 3 times daily for 30 days. Each night, participants rated the extent to which they responded to pain by catastrophizing, how much control they had over that day's pain, their ways of coping with pain that day, and the effectiveness of their coping efforts. Multivariate multilevel regression models revealed that after controlling for neuroticism and current depressive symptoms, formerly depressed and never-depressed individuals differed in how they coped with increased pain and in how they appraised the efficacy of their coping efforts. Formerly depressed participants who also reported more current depressive symptoms showed a greater decline in pleasant mood on more painful days than did formerly depressed participants who were experiencing fewer current depressive symptoms. These findings illustrate how a history of depression can be captured in the dynamics of daily life.     

Influence of dysphoria on positive and negative cognitive reactivity to daily mood fluctuations

We used an experience sampling design to investigate the influence of dysphoria on positive and negative cognitive reactivity. Participants recorded their thoughts and mood four times per day on PDA devices for one week. We hypothesized that those higher in dysphoria would demonstrate a greater increase in negative thinking in response to negative mood, and a weaker increase in positive cognitions in response to positive mood. These hypotheses were largely supported. For those participants who reported higher initial dysphoria, there was a stronger association between negative mood and thinking and a weaker link between positive mood and thinking. Regression analyses indicated that positive and negative cognitive reactivity were independently related to dysphoria, suggesting that they represent distinct processes. Our results highlight the importance of understanding levels of both negative and positive cognitive reactivity and underscore the benefits of assessing mood and cognition with repeated measurements in "real-time," in order to better understand the antecedent effects of mood on thinking.     

Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder

This study examined cognitive and affective predictors of treatment dropout and treatment efficacy in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD. Study participants were women with PTSD from a sexual assault who received at least one session of either treatment (n = 145) as part of a randomized clinical trial. Results revealed that younger age, lower intelligence, and less education were associated with higher treatment dropout, whereas higher depression and guilt at pretreatment were associated with greater improvement in PTSD symptomatology. Results by treatment condition indicated that women with higher anger at pretreatment were more likely to dropout of PE and that older women in PE and younger women in CPT had the best overall outcomes. These findings have implications for efforts to enhance treatment efficacy and retention in CBT treatment protocols.     

Cognitive reactivity as outcome and working mechanism of mindfulness-based cognitive therapy for recurrently depressed patients in remission

Major depressive disorder is a prevalent condition with high relapse rates. There is evidence that cognitive reactivity is an important vulnerability factor for the recurrence of depression. Mindfulness-based interventions are designed to reduce relapse rates, with cognitive reactivity as one of the proposed working mechanisms. In a randomised controlled trial we compared the effect of mindfulness-based cognitive therapy (MBCT) with treatment-as-usual (TAU) on cognitive reactivity in recurrently depressed patients (N?=?115). Depressive symptoms, cognitive reactivity, and mindfulness skills were assessed pre and post treatment. Patients in the MBCT group reported a significantly greater reduction in cognitive reactivity than those in the TAU group (d?=?.51). The reduction of cognitive reactivity appeared to mediate the association between MBCT/TAU and decrease of depressive symptoms, using pre and post scores. The current study provides evidence that MBCT reduces cognitive reactivity and preliminary evidence that cognitive reactivity is a working mechanism of MBCT.     

The cerebellum: Its role in language and related cognitive and affective functions

The traditional view on the cerebellum as the sole coordinator of motor function has been substantially redefined during the past decades. Neuroanatomical, neuroimaging and clinical studies have extended the role of the cerebellum to the modulation of cognitive and affective processing. Neuroanatomical studies have demonstrated cerebellar connectivity with the supratentorial association areas involved in higher cognitive and affective functioning, while functional neuroimaging and clinical studies have provided evidence of cerebellar involvement in a variety of cognitive and affective tasks. This paper reviews the recently acknowledged role of the cerebellum in linguistic and related cognitive and behavioral–affective functions. In addition, typical cerebellar syndromes such as the cerebellar cognitive affective syndrome (CCAS) and the posterior fossa syndrome (PFS) will be briefly discussed and the current hypotheses dealing with the presumed neurobiological mechanisms underlying the linguistic, cognitive and affective modulatory role of the cerebellum will be reviewed.     

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.     

Individual differences,mood, and coping with Chronic pain in Rheumatoid Arthritis: a daily process analysis

This study examines individual differences in coping and associated health outcomes as they unfold across time. Twice daily for one week, 71 individuals with Rheumatoid Arthritis reported their pain, coping efforts, and negative mood via structured daily records. The five factor model of personality (neuroticism, extraversion, openness to experience, agreeableness, conscientiousness) and disease status were also assessed. Multi-level statistical models examining within and between person variability indicated significant temporal associations from coping to pain and bi-directional associations between mood and pain within days. Furthermore, findings suggest that coping use and coping effectiveness were moderated by personality. Implications for models of coping with chronic pain, as well as clinical applications, are discussed.